Provider Demographics
NPI:1588646327
Name:SULLIVAN, WILLIAM R (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 KAY ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1625
Mailing Address - Country:US
Mailing Address - Phone:865-579-3920
Mailing Address - Fax:865-579-3963
Practice Address - Street 1:2020 KAY ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1625
Practice Address - Country:US
Practice Address - Phone:865-579-3920
Practice Address - Fax:865-579-3963
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD8558174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3155295Medicaid
TN3155295Medicaid
TN3155296Medicare ID - Type UnspecifiedBAPTIST PROVIDER NUMBER
TNB02563Medicare UPIN